Fetal acid-base state following spinal or epidural anesthesia for cesarean section.

The authors compared fetal acid-base state and maternal blood pressure response in 111 women undergoing repeat cesarean section with either epidural or spinal anesthesia. Fetal umbilical acidemia (umbilical venous pH less than 7.25 or umbilical arterial pH less than 7.20) was more commonly observed following spinal anesthesia with a preanesthetic fluid load of 500 to 999 ml (20% of cases) than with epidural anesthesia (4% of cases. P > .05, chi 2). The incidence of fetal acidemia following spinal anesthesia was similar to that following epidural anesthesia when 1000 to 1500 ml of fluid was infused prior to spinal anesthesia. The maximum reduction in systolic blood pressure following spinal anesthesia was not related to preanesthetic fluid load; however, in cases of severe hypotension the hypotensive episode was shorter and easier to treat when the preanesthetic fluid load was 1000 to 1500 ml rather than 500 to 999 ml. These data suggest that women receiving spinal anesthesia for repeat cesarean section should be given an intravenous fluid load of 1 liter or more.

Modified fluorometric quantitation of pancuronium bromide and metabolites in human maternal and umbilical serums.

The procedure for pancuronium bromid ion-pair extraction into chloroform using rose bengal and subsequent fluorometric measurement was modified by changing the extraction pH and eliminating phenol, ethanol, and acetone to give easier operation and enhanced fluorescence stability. Precision, accuracy, and sensitivty were evaluated over 0.14-0.82 microgram/ml (CV = 14; relative error = 9%) and 0.05-0.17 microgram/ml (CV = 19; relative error = 21%). Following a dose of 0.1 ml/kg for cesarean section in humans, the mean maternal arterial and umbilical venous serum concentrations of pancuronium bromide and metabolites were 0.52 and 0.12 microgram/ml, respectively, at delivery (mean of 13 min after injection).

Complications of the Ehlers-Danlos syndrome in pregnancy. A case report.

The Ehlers-Danlos syndrome (EDS) is a disorder of the connective tissue characterized by hyperextensible skin, loose jointedness, fragile tissues, bruising and bleeding diathesis. At least eight subtypes of EDS are recognized, each one with different clinical manifestations. On rare occasions EDS is associated with pregnancy. These patients are at risk for bleeding disorders and vascular, surgical and anesthetic complications as well as for premature labor, postpartum hemorrhage, bladder and uterine prolapse, abdominal hernias and wound dehiscence. We treated a pregnant patient for type 1 EDS and pregnancy-induced hypertension.

Etiology and incidence of endotracheal intubation following spinal anesthesia for cesarean section.

BACKGROUND: The incidence of spinal failure necessitating general anesthesia and endotracheal intubation following spinal anesthesia for cesarean section is extremely low. Aspiration prophylaxis prior to spinal anesthesia is often recommended in case of spinal failure or excessive spinal block requiring the emergency administration of general anesthesia. OBJECTIVES: To determine the incidence of endotracheal intubation following spinal anesthesia for cesarean section. METHODS: We retrospectively reviewed the peri-operative course of parturients undergoing cesarean section under spinal anesthesia at our institution from February 1991 to December 1993. If spinal failure occurred, 10 ml of sodium bicarbonate was administered by mouth prior to induction of general anesthesia. RESULTS: Among the 743 cases that we reviewed, spinal failure occurred in 15 patients (2%) because of inadequate analgesia in 14 patients (1.9%) and unexpected prolonged surgery for hysterectomy in one patient (0.1%). No patient required intubation due to excessive spinal block. In none of the patients was a record of pulmonary aspiration identified. CONCLUSIONS: The extremely low incidence of spinal failure or excessive block necessitating endotracheal intubation suggests that routine aspiration prophylaxis may not be necessary prior to spinal anesthesia. However, these results should be confirmed by a prospective, controlled study on larger populations. An antacid should be readily available and administered whenever general anesthesia is required.

Apnoea associated with the intrathecal administration of morphine in obstetrics. A case report.

The intrathecal administration of hyperbaric morphine 1 mg for pain relief during labour was followed, 7 h after injection, and 1 h after delivery, by respiratory depression. Pulseoximetry was helpful in alerting the medical personnel. After an initial 1 mg of naloxone i.v. in increments of 0.1-0.2 mg, a continuous infusion of naloxone 0.4 mg h-1 i.v. was used to prevent a recurrence of the respiratory depression. The total dose of naloxone over an 8-h period was 3.6 mg.

Obstetric anaesthesia and Ehlers-Danlos syndrome.

The obstetric and anaesthetic problems of Ehlers-Danlos syndrome are discussed. A new unclassified type of the syndrome is described. The possibility of bleeding presents a serious challenge for both the obstetrician and the anaesthetist. A detailed medical history, including family history, are important in determining the method of anaesthesia since blood coagulation tests are usually normal. The anaesthetic management of two parturients with Ehlers-Danlos syndrome is illustrated. Caudal, extradural, and subarachnoid block techniques for labour and Caesarean section were used safely on three occasions in these two patients.

Foetal bradycardia during caudal analgesia: A discussion of possible causative factors.

A 31-year-old female had caudal analgesia during labour, using 0.5% bupivacaine. Nine minutes after the block, the foetus developed severe bradycardia which lasted for 9 min but recovered spontaneously. Thereafter the foetal heart rate was within the normal range until the end of labour when variable decreases in rate occurred, suggesting cord compression. At the time of delivery there was a knot of the umbilical cord which was also forming a loop around the neck of the baby. There was no abnormality of the Apgar scores or blood-gases in the baby; the plasma bupivacaine concentrations in both mother and child were within the expected range. The possible causative factors for this bradycardia are explained.

Caudal analgesia for quadruplet delivery.

During the period January 1969 to November 1974, in a total of 39,800 deliveries, there were two sets of quadruplets. Both parturients had been taking ovulation-inducing drugs. Maternal problems were distended abdomen and heavy uterus, causing supine hypotension and lordosis; toxemia of pregnancy; increased possibility of hemorrhage before, during and/or after delivery; edema of the back; mental depression. The fetal problems were prematurity; intrauterine growth retardation; increased possibility of transfusion syndrome and prolapsed cord; increased obstetric manipulation. An adequate number of obstetricians, pediatricians, anesthesiologists, and nurses, necessary equipment, and blood and blood components should be available. Early hospitalization is necessary. Close observation of the patient before, during, and after delivery is essential. The patient should stay on her side throughout the labor. General anesthesia may add to fetal depression and increase the possibility of uterine atony. Spinal or lumbar epidural anesthesia may be difficult because of the associated lordosis and back edema. Caudal block allowed intrauterine manipulation; provided adequate analgesia, permitted high FIO2 administration, and did not interfere with voluntary bearing down when required.

Postpartum hypertension and convulsion after oxytocic drugs.

An 18-year-old primipara developed acute hypertension leading to cerebral edema and convulsions following the IV injection of a bolus of 10 units of oxytocin with 0.2 mg methylergonovine maleate. Oxytocin in a dose of more than 2 units should not be administered IV in a single injection, as severe hypotension may result. If oxytocin is required, it can be injected either IM, or by IV pump or drip. The use of ergot in obstetrics should be limited to the treatment of life-threatening postpartum hemorrhage and be given only by the IM route. Ergot should not be administered to patients with cardiac, renal, or hypertensive disease, or in association with a vasoconstrictor.

Epinephrine improves the quality of spinal hyperbaric bupivacaine for cesarean section.

In a double-blind randomized study, the effects of the addition of epinephrine on hyperbaric spinal bupivacaine were studied in 63 patients having elective repeat cesarean sections. In the study group (32 patients), the addition of 0.2 mg epinephrine improved the quality of analgesia since fewer patients required supplementation of the spinal anesthetic; the motor block was more profound; and the times to two-segment regression, sensory recovery, and motor recovery were prolonged.

Migration of an extradural catheter into the subdural space. A case report.

After repeated, successful extradural injections in a parturient, the extradural catheter migrated into the subdural space. The injection of 3% chloroprocaine 10 ml resulted in an extensive block, which extended to the cranial nerves and paralysed the respiratory muscles. The position of the catheter tip was confirmed by fluoroscopy. Subdural injection should always be suspected when tests for subarachnoid injection are negative, but an extensive block occurs gradually within 15-20 min. Respiration and circulation should be supported until the block regresses.

Acupuncture in obstetrics.

Electroacupuncture (ACP) during childbirth was used in 12 parturients. On the average, it produced 66 percent analgesia in 7 patients for 139 minutes while patients were in active, progressive labor. When ACP no longer could relieve pain, spinal, epidural, or double-catheter technic produced complete analgesia in all patients. ACP did not adversely affect the fetus or uterine contractions and had no harmful aftereffect on mother or neonate. However, its use as a routine method had disadvantages because analgesia was inconsistent, unpredictable, and incomplete. The technic was time-consuming, limited the patient's movement, added more wires and machinery, and interfered with electronic monitoring of the mother and fetus.

Effect of morphine-diazepam on signs of anesthesia, awareness, and dreams of patients under N2O for cesarean section.

Morphine (0.2 mg/kg) and diazepam (0.1 mg/kg) were injected IV after delivery of the fetus in 68 parturients undergoing cesarean section (CS). General anesthesia was with thiamylal-N2O-O2 (4:2) and muscle relaxant. Twenty-four to 36 hours postoperatively, 1 patient had recall, 1 had unpleasant dreams, and 2 had pleasant dreams. The incidence of recall and unpleasant dreams was 3.8 percent in elective CS and 0 percent in emergency cesareans. Morphine-diazepam combination caused anterograde and retrograde amnesia. During the cesarean, movement of patient, size of pupils, or changes in blood pressure were not indicative of awareness or dreams. During anesthesia, 33 percent O2 produced adequate oxygenation of mother and fetus.

Combined spinal-epidural analgesia in advanced labour.

The combined spinal-epidural technique is a modification of epidural analgesia which combines the rapid onset of spinal analgesia with the flexibility of an epidural catheter. We sought to evaluate the effectiveness of an intrathecal opioid--low-dose local anaesthetic combination for parturients in advanced labour, a setting where satisfactory epidural analgesia is often difficult to achieve. The technique was evaluated in an open-label, non-randomized trial using parturients in advanced, active labour for the provision of pain relief during the late first stage and second stage of labour. Thirty-eight term parturients in active, advanced labour received a spinal injection of bupivacaine 2.5 mg and sufentanil, 10 micrograms, via a 25- or 27-gauge Whitacre needle placed into the subarachnoid space through a 17- or 18-gauge Weiss epidural needle which had been placed into the epidural space. This was followed by placement of an epidural catheter for supplemental analgesia if required. Onset of analgesia was noted by asking patients if their contractions were comfortable. Motor blockade was assessed using the Bromage criteria. Patients were asked if they experienced either pruritus or nausea on a four-point scale (none, mild, moderate, severe). The mean cervical dilatation at placement of the spinal medication was 6.1 +/- 2.2 cm. Thirty-two patients had spontaneous vaginal delivery, two were delivered by outlet forceps, and four by Caesarean section. Onset of analgesia was rapid (< five minutes) in all cases. Twenty-three patients (60%) delivered vaginally with no additional anaesthetic. The remaining 15 had supplemental local anaesthetic given via the epidural catheter, a mean of 123 +/- 33 min after the original spinal dose.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined spinal and epidural anesthesia for cesarean section in a parturient with moyamoya disease.

We present the case of a parturient with moyamoya disease admitted to the hospital for elective cesarean section. Combined spinal and epidural technique was chosen because it allows better analgesia than epidural anesthesia and more hemodynamic stability than either general or spinal anesthesia. Ropivacaine was the local anesthetic of choice for the epidural portion because of the wide sensory-motor dissociation, thus preserving adequate respiration in the case of a high block.

Combined intrathecal morphine and bupivacaine for cesarean section.

The effects of adding 0.2 mg preservative-free morphine sulfate in 0.2 ml solution to hyperbaric spinal bupivacaine were evaluated in a double-blind randomized prospective study of 34 patients undergoing elective repeat cesarean section. In the control patients (n = 17), 0.2 ml saline instead of morphine was added to bupivacaine. The intrathecal morphine significantly improved intra- and postoperative analgesia, e.g., 82% of patients given morphine compared with 41% of the control patients did not require analgesic supplementation to the spinal anesthesia during surgery; postoperatively, the former patients did not request additional analgesia for 27 +/- 0.7 hours (mean +/- SEM) compared with 2 +/- 0.3 hours in the control patients. Neonatal condition was not adversely affected by this small dose of morphine administered 11 +/- 1 minutes before delivery. Combining 0.2 mg morphine with hyperbaric spinal bupivacaine for cesarean section is a safe and effective method of improving intraoperative pain relief and providing adequate prolonged postoperative analgesia.